Migraine with Aura Dr Jill Zelin for Prof Anne MacGregor Barts Health NHS Trust & Barts and the London School of Medicine and Dentistry .
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MIGRAINE WITH AURA
Dr Jill Zelin for Prof Anne MacGregor
Barts Health NHS Trust & Barts and the London School of Medicine and Dentistry
www.annemacgregor.comUK.PH.GM.X.2012.042d April 2012
OVERVIEW
What is migraine?What are the risks of hormonal contraception in women with migraine?What are the effects of hormonal contraceptives on migraine?
DO YOU HAVE THE FOLLOWING WITH YOUR HEADACHES?
Light bothers you more than usual?Your headaches limit your ability to work, study or do what you need to do for at least one day?You feel nauseated or sick?
Lipton et al Neurology 2003;61:375-82
Positive predictive value for migraine diagnosis: 2 positive answers – PPV = 93% 3 positive answers - PPV = 98%
DO YOU HAVE THE FOLLOWING WITH YOUR HEADACHES?
Light bothers you more than usual?Your headaches limit your ability to work, study or do what you need to do for at least one day? You feel nauseated or sick?
Lipton et al Neurology 2003;61:375-82
• 20-30% attacks• 1% without
headache
MIGRAINE
Migraine without aura Migraine with aura
• 70-80% attacks
IS IT AURA?
normalI
premonitoryII
auraIII
headacheIV
resolutionV
recovery normal
headache
food craving
tired/yawning
heightenedperception
anorexia/nausea/vomiting
malaise/ lethargy
sensitive to light/sound
heightened sense of smell
vomiting
sleep limited foodtolerance
tired
diuresis
poor concentration
difficulty focusing
fluid retention
hungover
drugs
2-24 hrs
WHEN DOES A MIGRAINE START?
Blau JN Lancet 1992;339:1202-7
<1 hr 4-72 hrs 2-12 hrs 2-24 hrs
PREMONITORY VISUAL SYMPTOMS
100
80
60
40
20
0
-150 -100 -50 0 50 100
premonitory
headache
Giffin N et al Neurology 2003;60:935-40
hours
VA
S r
atin
g o
f st
ate
of
hea
lth 28% reported blurred vision
49% reported light sensitivity
MIGRAINE AURA
99% visualScintillating scotoma Important points
Relationship to headacheStarts before Resolves before
DurationLasts less than 60 minutes - typically 20-30 mins
Symptoms are specific
DIAGNOSIS
Do you ever have visual disturbancesStarting before the headache?*Lasting up to one hour?Resolving before the headache?*
*Headache may be very very mild
MIGRAINE AURA AND ISCHAEMIC STROKE
Migraine aura is a marker for increased risk of ischemic stroke in young womenAssociated with increased risk of
DiabetesHigh cholesterolHypertensionSmoking
PROGESTOGEN-ONLY CONTRACEPTION
Not associated with any significant alteration in haemostasis Not associated with an increased risk of ischaemic stroke
Tzourio et al BMJ 1995;310:830-3WHO Contraception 1998;57:315-24
Heinemann et al Eur J Contracept Reprod Health Care 1999;4:67-73
CHCS AND ISCHAEMIC STROKE
Prothrombotic effectIncreased risk of ischemic stroke in current users of low dose pills (<50 mcg EE)
RR 1.93 (95% CI = 1.35-2.74)
Avoid additional factors that increase risk
Gillum et al JAMA 2000;284:72-8
UK MEDICAL ELIGIBILITY CRITERIA (UKMEC)
UKMEC 2009 www.fsrh.org
WHAT EFFECTS DO HORMONAL CONTRACEPTIVES HAVE ON MIGRAINE?
OESTROGEN AND MIGRAINE
Oestrogen ‘withdrawal’migraine without aura
‘menstrual’ migrainemigraine in the hormone-free interval of CHCs
High levels of oestrogenmigraine with aura
during CHC usepregnancyHRT
MIGRAINE DURING THE HORMONE-FREE INTERVAL
Natural oestrogen supplements during HFI100mcg patch on last day of pill packetReplace on 4th day of hormone-free intervalRemove on 1st day of next packet
Three day hormone-free interval TricycleContinuous (break with the bleed)
MacGregor EA, Hackshaw A J Fam Plann Reprod Healthcare 2002; 28:27-31
Calhoun A, Ford S Headache 2008;48:1186-1193
Sulak PJ et al Am J Obstet Gynecol 2002;186:1142-9
LaGuardia KD et al Fertil Steril 2005;83:1875-7
SUMMARY
Migraine aura is a marker of increased risk of ischemic strokeContraceptive use of CHCs contraindicated for women with migraine auraCHCs can be beneficial for migraine without aura!
WWW.BASH.ORG.UK
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